Provider Demographics
NPI:1679793897
Name:SULLIVAN, GLINDA MAE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GLINDA
Middle Name:MAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 4 SEASONS CTR
Mailing Address - Street 2:SUITE 106C
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3173
Mailing Address - Country:US
Mailing Address - Phone:573-528-7569
Mailing Address - Fax:
Practice Address - Street 1:106 4 SEASONS CTR
Practice Address - Street 2:SUITE 106C
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3173
Practice Address - Country:US
Practice Address - Phone:573-528-7569
Practice Address - Fax:314-439-5036
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024741103TC0700X
IL071.007644103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499462307Medicaid
MO000032552Medicare PIN